GPO Box 4221 Darwin NT 0801
HEALTH 2nd Floor Harbour View Plaza
Cnr McMinn & Bennett Streets Darwin NT 0800
Tel: +61 8 8999 4157 Fax: +61 8 8999 4196
APPLICATION FOR REGISTRATION/ENROLMENT
Mutual Recognition Act (Commonwealth) 1992, Section 19 Notice
Trans Tasman Mutual Recognition Act (Commonwealth) 1997, Section 18 Notice
I hereby apply for Registration / Enrolment / Authorisation to practise in a restricted practice area:
Chiropractor Registered Nurse Optometrist
Dentist + Authorisation as an
Authorisation as a Midwife
Optometrist to supply ocular
Dental Specialist Authorisation as a Nurse therapeutics ^
Dental Hygienist Practitioner Osteopath
Dental Therapist Direct Entry Midwife Pharmacist
Dental Prosthetist Medical Practitioner * Physiotherapist
Enrolled Nurse Occupational Therapist Psychologist
MIDWIVES - If you are a Registered Nurse who has qualifications to practise in the restricted practise area of midwifery tick both the
‘Registered Nurse’ box and the ‘Authorisation as a Midwife’ box. You will need to pay a registration fee of $75 plus the additional fee of $25
for authorisation to practise in a restricted practice area (total fee $100).
* MEDICAL PRACTITIONERS - Please note that Medical Practitioners can only apply under the Mutual Recognition Act and are not
eligible to apply under Trans Tasman Mutual Recognition Act.
^ OPTOMETRISTS – If you are an Optometrist who has qualifications to practise in the restricted practise area of supplying ocular
therapeutics please tick both the ‘Optometrist’ box and ‘Authorisation to Supply Ocular Therapeutics’ box. You will need to pay a
registration fee of $35 plus the additional fee of $25 for authorisation to practise in a restricted practice area (total fee $60).
Dr Mr Mrs Miss Ms (please tick as appropriate)
FORMER NAMES OR ALIASES: (if applicable)
DATE OF BIRTH: / / COUNTRY OF BIRTH:
GENDER: Male Female (please tick as appropriate)
TELEPHONE NO: (bh) (ah) (mobile)
FAX NO: EMAIL:
Educational qualifications (include institution and year of graduation):
* PLEASE NOTE DOCUMENTS REQUIRED TO COMPLETE APPLICATION ON PAGE 4*
MR & TTMR Form February 2008 1 of 4
Last practising position was at:
Dates held: From: / / To: / /
Date commencing practise in the Northern Territory: / /
Intended place of practice in the Northern Territory (if unknown please state):
Have you ever been registered/enrolled/licensed in the Northern Territory before? Yes No
If yes, what was your registration/enrolment/licence number?
NOTE: The Health Professions Licensing Authority may from time to time allow organisations to access names and business
addresses only of practitioners registered in the Northern Territory, if the organisation can demonstrate and satisfy the Board
that the use of the data will, or has, the potential to contribute to the acquisition of knowledge that may improve the health of the
PAYMENT OPTIONS (DO NOT SEND CASH)
It is recommended that you do not send cash via postal mail. Cash will only be accepted at the Counter.
Bankcard/Visa/MasterCard are the only Credit Cards accepted.
Fee of $ is enclosed payable by Cheque Money Order
Card Type Bankcard Visa MasterCard
Signature Name (print)
SCHEDULE OF FEES
Chiropractor $300 valid to 30 Sept Medical Practitioner $150 valid to 30 Sept
Dentist $180 valid to 30 Sept Occupational Therapist $40 valid to 30 Sept
Dental Specialist $180 valid to 30 Sept Optometrist $35 valid to 30 Sept
Dental Hygienist $30 valid to 30 Sept Osteopath $300 valid to 30 Sept
Dental Therapist $30 valid to 30 Sept Pharmacist $35 valid to 30 Sept
Dental Prosthetist $30 valid to 30 Sept Physiotherapist $70 valid to 30 Sept
Enrolled Nurse $75 valid to 30 Sept Psychologist $40 valid to 30 Sept
Registered Nurse $75 valid to 30 Sept Authorisation to practise in
a restricted practice area - add $25 valid to 30 Sept
Direct Entry Midwife $75 valid to 30 Sept
IMPORTANT - Please read the following before completing the rest of the form:
• If you are not able to answer ‘true’ to statements 3, 4, 5 and 6 in the Statutory Declaration you may not
be eligible to lodge a notice under section 19 of the Mutual Recognition Act or section 18 of the Trans
Tasman Mutual Recognition Act and should enquire with the Board as to how you should make an
application for registration.
• If you are licensed with conditions please advise how you intend to satisfy these conditions in the
• Incomplete notices of application, including omission of payment of the appropriate fee and required
documents, will not be accepted by the Board resulting in deferment of the right to practise.
• Statements or information, which are materially false or misleading, may result in postponement or
refusal of registration.
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COMMONWEALTH OF AUSTRALIA
NOTE: All questions and statements must be completed (please tick appropriate box where applicable)
(Given Name) (Surname)
hereby seek registration/enrolment/licence/authorisation to practise in accordance with the mutual recognition principle and in
support of my application do solemnly and sincerely declare as follows:
1. I am currently registered/enrolled/licensed/authorised to practise in the following State/Territory/Country, which is the
State/Territory/Country on which I base my application for registration.
2. I also currently hold or have held registration/enrolment/licence/authorisation to practise in the following
3. I consent to the Health Professions Licensing Authority of the Northern Territory making enquiries of
and the exchange of information with the authorities of any State/Territory/Country regarding my
activities as a health practitioner. Yes No
4. I am not the subject of disciplinary proceedings in any State/Territory/Country or any preliminary
investigations or action that might lead to disciplinary proceedings in relation to my practise as a
health practitioner. True False
5. My registration/enrolment/licence/authorisation has not been cancelled nor is it currently suspended
as a result of disciplinary action in any State/Territory/Country. True False
6. I am not otherwise personally prohibited from carrying out practise as a health practitioner as a
result of criminal, civil or disciplinary proceedings in any State/Territory/Country. True False
7. My registration in another State/Territory/Country is not subject to any other special conditions,
limitations or restrictions. True False
8. I am not suffering from a mental or physical disability, which would prevent me practising efficiently. True False
9. I have not practised unlicensed in the Northern Territory. True False
If “False” to any of the above, please provide full details on an attached signed sheet.
And I make this solemn declaration by virtue of the Statutory Declarations Act 1959 of the Commonwealth and subject to the
penalties provided by that Act for the making of false statements in statutory declarations, conscientiously believing the statements
contained in this declaration to be true in every particular.
Signature of person making declaration:
Declared at: on the: day of: 20
Signature of person witnessing declaration:
Name of witness (printed):
Title of witness (printed), if applicable:
Address or telephone number of witness:
The Statutory Declaration may be signed by a Justice of the Peace, Solicitor or by a person authorised within your State/
Territory/Country to witness statutory declarations/affidavits. Only if you are physically located in the Northern Territory, then the
declaration may be witnessed before any person who has attained the age of 18 (eighteen) years.
MR & TTMR Form February 2008 3 of 4
DOCUMENTS AND OTHER REQUIREMENTS FOR
The following documents MUST be provided with this application form. Photocopies
will only be accepted if they have been certified to be a true copy by: a Justice of
the Peace, Commissioner for Oaths, Police Officer, Solicitor, Bank Manager, Postal
Manager, Pharmacist, Australian Defence Force Commissioned Officer, NCO or
Warrant Officer; or the originals sighted by an authorised Health Professions
Licensing Authority staff member. It is not recommended that you send originals by
post. Certified copies will be retained on file.
Evidence of current registration/enrolment in Australian or New Zealand
(Annual Practising Certificate or Certificate of Registration issued within the last
Proof of Identity
(Provide one of the following: Drivers Licence; Passport; Birth Certificate; or
Statutory Declaration attesting to the applicant’s identity or other form of official
Evidence of Name Change (Marriage Certificate, Divorce Decree or Deed Poll)
An application and registration fee in Australian dollars
(see Payment Options and Schedule of Fees sections of this form).
All parts of application form completed in full.
TO ASSIST IN THE TIMELY PROCESSING OF YOUR APPLICATION, PLEASE
ENSURE THAT YOU HAVE ATTACHED THE ABOVE MENTIONED CERTIFIED
DOCUMENTS TO YOUR COMPLETED APPLICATION FORM.
On completion of your application form please send your application and
supporting documentation by one of the following methods to Health
Professions Licensing Authority:
Post: Health Professions Licensing Authority
GPO Box 4221
Darwin NT 0801
Hand Deliver: 2nd Floor Harbour View Plaza
Cnr McMinn & Bennett Streets
Darwin NT 0800
Facsimile: +61 8 8999 4196
If you have any queries regarding your application please contact us on:
Phone: +61 8 8999 4157
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